Review Article
Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures Cam Tu Nguyen, Eunice Lee, Huai Luo, Robert J Siegel Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA Corresponding to: Robert J Siegel, MD, FACC. 8700 Beverly Blvd. Rm 5623, Los Angeles, CA 90048, USA. Tel: (310) 423-3849; Fax: (310) 423-8571. Email: [email protected].
Abstract: Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes. Key Words: Percutaneous cardiovascular procedures; vascular access; echocardiographic guidance Submitted Sep 16, 2011. Accepted for publication Sep 24, 2011. doi: 10.3978/j.issn.2223-3652.2011.09.02 Scan to your mobile device or view this article at: http://www.thecdt.org/article/view/37
Introduction Echocardiography is beneficial for guiding numerous percutan-eous cardiovascular procedures of the pericardium, myocardium, and cardiac valves. It also plays an important role in guiding vascular access. The advantages of echocardiographyinclude mobility and real time imaging, which allow for assessment before, during, and after procedures. Ultrasound imaging is widely available, portable, and offers clear images to help evaluate the severity of valvular disease, surrounding structures, and the location of catheters and devices. These benefits enhance the efficiency and safety of diagnostic and therapeutic procedures. This article will address the advantages and the role of ultrasound imaging in percutaneous procedures, namely, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, pulmonary valve repair, transcatheter aortic valve implantation, and mitral valve repair. Transvenous access Physicians place millions of central venous catheters (CVC)
© Cardiovascular Diagnosis and Therapy. All rights reserved.
each year in the United States. Central venous access is commonly indicated for hemodynamic monitoring, hemodia-lysis, and administration of fluids, medications and nutrition. Unfortunately, the complication rate associated with the procedure exceeds 15% (1). Types of complications include infection, thrombosis, and mechanical, all of which depend on several factors such as operator experience, patient anatomy, and procedure characteristics (2,3). Common mechanical complications are arterial puncture, pneumothorax, hematoma, and hemothorax; these are reported to occur in 5 to 19% of patients (1,4,5). Complications may compromise patient safety and are expensive to treat, thus minimizing adverse events is beneficial. Ultrasound (US) guidance for the insertion of central lines, particularly through the internal jugular vein (IJ), has been shown to reduce mechanical complications, improve success rates, reduce number of attempts, and time required for insertion when compared to the technique of using external anatomic landmarks (6,9). The internal jugular, subclavian, and femoral veins are
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Cardiovasc Diagn Ther 011;1(1):11-36
12
common sites for central venous access. Successful catheterization using the landmark technique relies on a thorough understanding of anatomic landmarks at these sites. However, there is significant variability in anatomic structures in relation to the target veins (10,11). Thus, real-time (RT) US guidance allows operators to clarify the relative position of the needle, the desired vein, and the surrounding anatomy prior to and during CVC insertions (2,3). In a meta-analysis of studies comparing RT US guidance method with the landmark method for central line placement, Randolph et al. observed that US guidance decreased complications during attempted CVC placements (relative risk 0.22, confidence interval [CI] 0.10-0.45), corresponding to a relative risk reduction of 78% and reduced placement failures (relative risk 0.32, 95% CI: 0.18-0.55) when compared to the landmark method (12). In addition, the mean number of attempted venipunctures was significantly reduced with US guidance (relative risk 0.60, 95% CI: 0.45-0.79), corresponding to a relative risk reduction of 40%. In a recent meta-analysis of studies comparing two-dimensional (2D) US guidance or Doppler US guidance method with the landmark method, Hind et al. also observed similar results. For IJ insertions, 2D US guidance reduced complications (relative risk 0.43, 95% CI: 0.22-0.87), and decreased placement failure (relative risk 0.14, 95% CI: 0.06-0.33), when compared to the landmark method (2). They also observed that fewer attempts were required for successful placement and less time needed with 2D US guidance. Other subsequent studies also suggest that US guided IJ catheterization was associated with a higher success rate and a lower complication rate. In a randomized, prospective study of RT US guided IJ catheterization in the emergency department (ED), Leung et al. observed that IJ cannulation was successful in 93.9% with US guidance method compared to 78.5% with the landmark method, a significant difference of 15.4% (P=0.009, 95% CI: 3.8% to 27.0%). Of the successful US guided catheterizations, 82.0% were inserted on the first attempt compared to 70.6% of the successful landmark catheters. The complication rate was observed in 4.6% in the US guidance method compared to 16.9% in the landmark method, a difference of 12.3% (95% CI 1.9% to 22.8%) (13). In a recent randomized, prospective study, Turker et al. also observed similar results with the US guided method having fewer number of attempts for successful insertion and a lower complication rate when compare to the landmark method(P
Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures Cam Tu Nguyen, Eunice Lee, Huai Luo, Robert J Siegel Cedars Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA Corresponding to: Robert J Siegel, MD, FACC. 8700 Beverly Blvd. Rm 5623, Los Angeles, CA 90048, USA. Tel: (310) 423-3849; Fax: (310) 423-8571. Email: [email protected].
Abstract: Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes. Key Words: Percutaneous cardiovascular procedures; vascular access; echocardiographic guidance Submitted Sep 16, 2011. Accepted for publication Sep 24, 2011. doi: 10.3978/j.issn.2223-3652.2011.09.02 Scan to your mobile device or view this article at: http://www.thecdt.org/article/view/37
Introduction Echocardiography is beneficial for guiding numerous percutan-eous cardiovascular procedures of the pericardium, myocardium, and cardiac valves. It also plays an important role in guiding vascular access. The advantages of echocardiographyinclude mobility and real time imaging, which allow for assessment before, during, and after procedures. Ultrasound imaging is widely available, portable, and offers clear images to help evaluate the severity of valvular disease, surrounding structures, and the location of catheters and devices. These benefits enhance the efficiency and safety of diagnostic and therapeutic procedures. This article will address the advantages and the role of ultrasound imaging in percutaneous procedures, namely, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, pulmonary valve repair, transcatheter aortic valve implantation, and mitral valve repair. Transvenous access Physicians place millions of central venous catheters (CVC)
© Cardiovascular Diagnosis and Therapy. All rights reserved.
each year in the United States. Central venous access is commonly indicated for hemodynamic monitoring, hemodia-lysis, and administration of fluids, medications and nutrition. Unfortunately, the complication rate associated with the procedure exceeds 15% (1). Types of complications include infection, thrombosis, and mechanical, all of which depend on several factors such as operator experience, patient anatomy, and procedure characteristics (2,3). Common mechanical complications are arterial puncture, pneumothorax, hematoma, and hemothorax; these are reported to occur in 5 to 19% of patients (1,4,5). Complications may compromise patient safety and are expensive to treat, thus minimizing adverse events is beneficial. Ultrasound (US) guidance for the insertion of central lines, particularly through the internal jugular vein (IJ), has been shown to reduce mechanical complications, improve success rates, reduce number of attempts, and time required for insertion when compared to the technique of using external anatomic landmarks (6,9). The internal jugular, subclavian, and femoral veins are
www.thecdt.org
Cardiovasc Diagn Ther 011;1(1):11-36
12
common sites for central venous access. Successful catheterization using the landmark technique relies on a thorough understanding of anatomic landmarks at these sites. However, there is significant variability in anatomic structures in relation to the target veins (10,11). Thus, real-time (RT) US guidance allows operators to clarify the relative position of the needle, the desired vein, and the surrounding anatomy prior to and during CVC insertions (2,3). In a meta-analysis of studies comparing RT US guidance method with the landmark method for central line placement, Randolph et al. observed that US guidance decreased complications during attempted CVC placements (relative risk 0.22, confidence interval [CI] 0.10-0.45), corresponding to a relative risk reduction of 78% and reduced placement failures (relative risk 0.32, 95% CI: 0.18-0.55) when compared to the landmark method (12). In addition, the mean number of attempted venipunctures was significantly reduced with US guidance (relative risk 0.60, 95% CI: 0.45-0.79), corresponding to a relative risk reduction of 40%. In a recent meta-analysis of studies comparing two-dimensional (2D) US guidance or Doppler US guidance method with the landmark method, Hind et al. also observed similar results. For IJ insertions, 2D US guidance reduced complications (relative risk 0.43, 95% CI: 0.22-0.87), and decreased placement failure (relative risk 0.14, 95% CI: 0.06-0.33), when compared to the landmark method (2). They also observed that fewer attempts were required for successful placement and less time needed with 2D US guidance. Other subsequent studies also suggest that US guided IJ catheterization was associated with a higher success rate and a lower complication rate. In a randomized, prospective study of RT US guided IJ catheterization in the emergency department (ED), Leung et al. observed that IJ cannulation was successful in 93.9% with US guidance method compared to 78.5% with the landmark method, a significant difference of 15.4% (P=0.009, 95% CI: 3.8% to 27.0%). Of the successful US guided catheterizations, 82.0% were inserted on the first attempt compared to 70.6% of the successful landmark catheters. The complication rate was observed in 4.6% in the US guidance method compared to 16.9% in the landmark method, a difference of 12.3% (95% CI 1.9% to 22.8%) (13). In a recent randomized, prospective study, Turker et al. also observed similar results with the US guided method having fewer number of attempts for successful insertion and a lower complication rate when compare to the landmark method(P
